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Which Clinical Features of Children on Initial Presentation to the Emergency Department With Head Injury Are
James Burns1, Stephen Rohl, Daniel Marth
1From the Pediatric Trauma Research Team, Studer Family Children's Hospital at Ascension Sacred Heart.
Insights
Seizures, apnea, and lack of reported injury mechanism in young children presenting to the emergency department are key indicators of clinically important traumatic brain injury (TBI) and abusive head trauma (AHT). These findings aid in identifying severe pediatric head injuries.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Child Abuse Pediatrics
Background:
- Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are significant causes of child morbidity and mortality.
- Early identification of AHT in the emergency department (ED) setting is crucial but often challenging for clinicians.
Purpose of the Study:
- To identify clinical features present at ED trauma bay arrival that predict clinically important TBI (CiTBI).
- To determine predictors for classification as confirmed abuse by a Child Protection Team (CPT).
- To identify factors associated with poor neurologic status upon hospital discharge.
Main Methods:
- Study included children aged 3 years or younger with significant TBI, including those with unverified injury mechanisms.
- Data were sourced from a regional trauma registry, hospital records, and the CPT database.
- Analysis involved demographics, injury mechanisms, physical and radiological findings, and CPT classifications.
Main Results:
- Seizures, apnea, and lack of reported injury mechanism were associated with all three outcomes (CiTBI, confirmed abuse, poor neurologic status).
- Features linked to AHT included rib fractures, long bone fractures, retinal hemorrhages, seizures, apnea, and age under 6 months.
- Multivariable analysis confirmed that lack of reported injury mechanism and seizures predicted CiTBI; seizures and retinal hemorrhage predicted abuse classification; lack of reported injury mechanism, apnea, and seizures predicted poor outcome.
Conclusions:
- Lack of reported injury mechanism, seizures, and apnea are critical indicators for CiTBI, AHT classification, and poor prognosis in pediatric head injuries.
- Younger age, retinal hemorrhage, and fractures of the ribs or long bones are significant clinical features associated with AHT.
Background:
Pediatric traumatic brain injury (TBI) and abusive head trauma (AHT) are leading causes of morbidity and mortality. Clinicians may not be aware of AHT at presentation to the emergency department (ED).
Objective:
The objective of this study was to determine which clinical features associated with head injury in children on initial presentation to the ED trauma bay predict 3 outcomes including clinically important TBI (CiTBI), classification as confirmed abuse by Child Protection Team (CPT), and poor neurologic status on hospital discharge.
Participants And Setting:
Inclusion for this study were children 3 years or younger, presenting to the ED with significant TBI. In addition, presentations where the mechanism of injury was not verifiable such as with falls, being struck by object, or no mechanism of injury reported by caregiver were included.
Methods:
Researchers used 3 sources of information for this analysis: a regional trauma registry, hospital records, and the CPT database. Clinical features included demographics, mechanisms of injury, physical, radiological findings, and CPT classification.
Results:
On pairwise analysis, seizures, apnea, and no mechanism of injury reported by caregiver were the only clinical features related to all 3 outcomes (P < 0.001). Rib fractures (relative risk [RR], 3.3; P < 0.001), long bone fractures (RR, 3.1; P < 0.001), retinal hemorrhages (RR, 3.0; P < 0.001), seizures (RR, 3.6; P < 0.001), apnea (RR, 4.4; P < 0.001), and younger than 6 months (RR, 1.8; P < 0.001) were related to AHT. On multivariable logistic regression, no mechanism of injury reported by caregiver and seizures remained significantly related to CiTBI; seizures and retinal hemorrhage remained significantly related to classification as abuse by CPT, and no mechanism of injury by the caregiver, apnea, and seizures were significantly related to poor outcome on hospital discharge.
Conclusions:
No mechanism of injury reported by the caregiver, seizures, and apnea at the time of presentation to the ED are important features associated with CiTBI, classification as AHT, and poor prognosis. In addition, younger age, retinal hemorrhage, rib, and long bone fractures were found to be important clinical features associated with AHT.
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